Jemds.com Original Research Article ROLE OF CANINE FOSSA PUNCTURE IN ENDOSCOPIC SINUS SURGERY - OUR EXPERIENCE J. S. Matta1, Nikhil Soni2, S. S. Kaushik3 1Professor and HOD, Department of ENT, American International Institute of Medical Sciences, Udaipur. 2Senior Resident, Department of ENT, American International Institute of Medical Sciences, Udaipur. 3Senior Resident, Department of ENT, American International Institute of Medical Sciences, Udaipur. ABSTRACT BACKGROUND Objectives Chronic rhinosinusitis is a chronic disease that involves long-term inflammation of nasal and paranasal sinus mucosa (Benninger et al 2003). It is extremely a common condition affecting about 15% population. The maxillary sinus is one of commonest sinus to affect. Aetiology of chronic maxillary sinusitis is either rhinogenous or dental origin as proposed. The evidence of chronic maxillary sinusitis in the population was 0.02% and dental cause was found in 40.6% of cases. Nowadays, we perform endoscopic sinus surgery to eradicate the pathology and widening of ostiomeatal complex, but there are so many hidden area of maxillary sinus which cannot be reached by ESS alone. To overcome these shortcomings, canine fossa puncture with endoscopic sinus surgery is a useful procedure to fully visualise maxillary antrum and to deal with pathology in it. So we have conducted this study in our Institution to see the impact of Canine Fossa Puncture (CFP) with clearance of the maxillary sinus during endoscopic sinus surgery in severely diseased maxillary sinus. Study Design - Retrospective. MATERIALS AND METHODS 60 patients underwent canine fossa puncture with endoscopic middle meatal clearance of the maxillary sinus. At an average postoperative time of 3 months, all patients underwent post-op CT scan. Lund-Mackay scoring system was applied on pre- and post-op CT scans.(5) RESULTS 72 sides were taken for analysis from 60 patients. All the patients were diagnosed with total opacification of maxillary sinus on contrast enhanced CT scan. On preoperative contrast enhanced computed tomography of nose and paranasal sinuses according to Lund-Mackay scoring system for all sinuses were scored 16.45 ± 3.6 and for maxillary sinus was 2. Computed tomography of nose and paranasal sinuses taken at 3 months post-operatively according to Lund-Mackay scoring system for all sinuses were 5.45 ± 0.98 and for maxillary sinus was 0.83 ± 0.98. CONCLUSION CFP is a useful technique to address the severely diseased maxillary sinus and is associated with significantly better symptom control compared with the transnasal middle meatal antrostomy clearance of the maxillary sinus. KEYWORDS CFP - Canine Fossa Puncture, MMA - Middle Meatus Antrostomy, ESS - Endoscopic Sinus Surgery. HOW TO CITE THIS ARTICLE: Matta JS, Soni N, Kaushik SS. Role of canine fossa puncture in endoscopic sinus surgery - our experience. J. Evolution Med. Dent. Sci. 2017;6(1):23-26, DOI: 10.14260/Jemds/2017/7 BACKGROUND The roof of sinus forms the major part of the floor of the The maxillary sinus is the largest of the paranasal sinuses. It orbit. It contains the infra-orbital canal which may exhibit fills body of maxilla and is pyramidal in shape. The base is dehiscence. The lateral truncated apex of the pyramid medial and forms much of the lateral wall of the nasal cavity. extends into the zygomatic process of maxilla and may reach The floor, which often lies below the nasal floor, is formed by the zygomatic bone, in which case it forms the zygomatic the alveolar process and part of palatine process of maxilla. It recess which throws a V-shaped shadow over the antrum on is related to the roots of the teeth, especially the 2nd a lateral radiograph. The facial surface of maxilla forms its premolar and 1st molar, but may extend posteriorly to the 3rd anterior wall and is grooved internally by a delicate canal molar tooth or anteriorly to incorporate the 1st premolar and (canalis sinuosus), which houses the anterior superior sometimes the canine. alveolar nerve and vessels as they pass forwards from the Financial or Other, Competing Interest: None. infra-orbital canal. The posterior wall is formed by the infra- Submission 12-12-2016, Peer Review 24-12-2016, temporal surface of the maxilla: it contains alveolar canals Acceptance 27-12-2016, Published 02-01-2017. that may produce ridges in the sinus and that also conduct Corresponding Author: the posterior superior alveolar vessels and nerves to the Dr. J. S. Matta, 1 Sardarpura, molar teeth. The medial wall is deficient postero-superiorly at Udaipur-313001, Rajasthan. the maxillary hiatus, a large opening which is partially closed E-mail: [email protected] in an articulated skull by portions of the perpendicular plate DOI: 10.14260/jemds/2017/7 of palatine bone, the uncinate process of ethmoid bone, the inferior nasal concha, the lacrimal bone and the overlying J. Evolution Med. Dent. Sci./eISSN- 2278-4802, pISSN- 2278-4748/ Vol. 6/ Issue 01/ Jan. 02, 2017 Page 23 Jemds.com Original Research Article nasal mucosa, to form an ostium and anterior and posterior fontanelles. The ostium usually opens into the inferior part of the ethmoidal infundibulum, and thence into the middle meatus via the hiatus semilunaris (the hiatus forms the area above the superior edge of the uncinate process). The fontanelles are covered only by periosteum and mucosa and may contain accessory ostia. All openings are nearer the roof than the floor of the sinus, which means that the natural drainage of the maxillary sinus is reliant on an intact mucociliary escalator: the cilia of the sinus mucoperiosteum normally beat towards the ostium. The maxillary sinus may be incompletely divided by septa; complete septa are very rare. The thinness of its wall is clinically significant in determining the spread of tumours from the maxillary sinus. A tumour may push up the orbital floor and displace the eyeball; project into the nasal cavity causing nasal obstruction and bleeding; protrude onto the cheek causing swelling and numbness if the infraorbital nerve is damaged; spread back into the infratemporal fossa causing Pre-Operative CT Scan showing Complete restriction of mouth opening due to pterygoid muscle damage Opacification of Left Maxillary Sinus and pain or spread down into the mouth, loosening teeth and malocclusion. Hypoplasia of maxillary antrum is present in up to 0.3% of the population. Ostiomeatal Complex The term ostiomeatal complex or ostiomeatal unit refers to the area that includes the maxillary sinus ostium, ethmoid infundibulum and the hiatus semilunaris. It is the common pathway for drainage of secretions from the maxillary and anterior group of ethmoidal sinuses, where the uncinate process attaches to the lateral nasal wall, the complex also drains the frontal sinus. Endoscopic Sinus Surgery (ESS) is performed on patients with chronic rhinosinusitis with or without nasal polyposis who are refractory to medical therapy. The maxillary sinus is one of the most commonly affected sinus with other paranasal sinus (anterior ethmoids mainly) and endoscopic Figure showing Site of Canine Fossa Puncture approach is mainly focused on widening of natural ostium (middle meatus antrostomy), this provides adequate access MATERIALS AND METHODS to the posterior, lateral and superior regions, but this This is a retrospective study performed in patients suffering technique is unsatisfactory for accessing anterior, medial, from chronic rhinosinusitis with or without nasal polyposis inferior areas of maxillary antrum. In such cases, many with extensive disease in maxillary sinus (total or near total otolaryngologists occasionally choose the traditional opacification) seen on preoperative CT scans. These patients Caldwell-Luc operation or inferior meatal antrostomy to underwent endoscopic sinus surgery with canine fossa visualise the blind area. However, these procedures provide puncture between December 2015 and July 2016 at our limited access and associated with significant morbidities. To Institute. The exclusion criteria were as follows: patients overcome these problems, canine fossa puncture with ESS is younger than 12 years, because before that maxillary sinus highly effective means of clearing disease from all these are not fully developed. Patient who had undergone Caldwell- inaccessible area as well as visualisation of these areas to Luc operation and patient suffering from acute sinus assess clearance of disease and with minimal complications infection. Patient who declined for the procedure or opted as compared to traditional procedures. Studies show that the out of the study. All the patients went through a preoperative optimal placement of the CFP should be at the junction of contrast enhanced computed tomography of nose and imaginary mid pupillary line and a horizontal line drawn paranasal sinuses. All the routine clinical laboratory through the floor of the nasal vestibule. The said area of CFP investigations were done preoperatively. All the patients decreases the risk of injury to major nerve trunks. Other than were fit for general anaesthesia. All the surgical procedures CRS, nasal polyposis, canine fossa puncture is useful in fungal were done under general anaesthesia. Before giving general sinusitis, eosinophilic mucin, mucopyoceles, foreign bodies, anaesthesia, nasal decongestion was achieved by using 4% any dental pathology or any combination thereof. lignocaine with adrenaline solution. The techniques used for The study is designed to assess the outcome of canine endoscopic sinus surgery